Crowdsourcing Electronic Health Record Improvements at Scale across an Integrated Health Care Delivery System

BACKGROUND AND OBJECTIVE

 Despite widespread adoption of electronic health records (EHRs), these systems have significant room for improved efficiency and efficacy. While the idea of crowdsourcing EHR improvement ideas has been reported, little is known about how this might work across an integrated health care delivery system in practice.

METHODS

 Our program solicited EHR improvement submissions during two timeframes across 10 hospitals and 60 clinics in an upper-Midwest integrated health care delivery system. Submissions were primarily collected via an EHR help feature.

RESULTS

 A total of 262 and 294 submissions were received in 2019 and 2022, with a majority initiated from physicians (73.5 and 46.9%, 2019 and 2022) specializing in family medicine (52.0 and 59.3%). In 2022, the program reached a larger variety of personnel than 2019, with 53.0% of submissions from advanced practice providers, nurses, administrative staff, and other roles (p < 0.0001). Many ideas (36.4 and 50.0% in 2019 and 2022) reflected a lack of user understanding of EHR features and were addressed through training/education. Significant (27.1 and 25.9%) or simple (24.0 and 14.7%) EHR optimizations were required to address most remaining suggestions, with a number part of planned EHR improvement projects already (16.3 and 17.6%).

CONCLUSION

 Our experience using a crowdsourcing approach for EHR improvement ideas provided clinicians and staff the opportunity to address frustrations with the EHR and offered concrete feedback and solutions. While previous studies have suggested EHR technology improvements as paramount, we observed large numbers of users having a misunderstanding of EHR features, highlighting the need for improved EHR user competency and training.

Observation of persistent species temperature separation in inertial confinement fusion mixtures

The injection and mixing of contaminant mass into the fuel in inertial confinement fusion (ICF) implosions is a primary factor preventing ignition. ICF experiments have recently achieved an alpha-heating regime, in which fusion self-heating is the dominant source of yield, by reducing the susceptibility of implosions to instabilities that inject this mass. We report the results of unique separated reactants implosion experiments studying pre-mixed contaminant as well as detailed high-resolution three-dimensional simulations that are in good agreement with experiments. At conditions relevant to mixing regions in high-yield implosions, we observe persistent chunks of contaminant that do not achieve thermal equilibrium with the fuel throughout the burn phase. The assumption of thermal equilibrium is made in nearly all computational ICF modeling and methods used to infer levels of contaminant from experiments. We estimate that these methods may underestimate the amount of contaminant by a factor of two or more.

Obesity and recovery of muscle strength after anterior cruciate ligament reconstruction in pediatric patients

PURPOSE:

To explore factors influencing muscle strength after anterior cruciate ligament (ACL) reconstruction (ACLR) in pediatric patients. We hypothesized that obesity/overweight, autograft hamstring tendon, and concomitant injuries would be associated with slower muscle recovery.

METHODS:

We retrospectively reviewed the records of pediatric ACLR patients during a 3-year period. Muscle recovery was defined as ≥85% of peak torque compared with the contralateral side. We categorized patients as either obese/overweight or normal weight. Statistical analysis was performed using Mann-Whitney U, analysis of variance, and χ² tests ( α level < 0.05).

RESULTS:

The study group consisted of 330 patients, of whom 198 (60%) and 231 (70%) met quadriceps and hamstring recovery criteria, respectively, at final testing (mean: 7.0 ± 3.2 months). Patients recovered hamstring and quadriceps strength at a mean of 5.3 ± 2.2 months and 6.1 ± 2.3 months, respectively. Hamstring muscle recovery took significantly longer in obese/overweight patients (mean: 5.7 ± 2.2 months) versus normal-weight patients (mean: 5.1 ± 2.1 months; p = 0.025), but quadriceps recovery did not (obese/overweight mean: 6.5 ± 2.6 months; normal-weight mean: 5.9 ± 2.1 months; p = 0.173).

CONCLUSION:

Concomitant injuries and graft type were not associated with length of time to recovery of muscle strength. Obesity/overweight was associated with delay in recovery of hamstring but not quadriceps strength.

Abstract P1-01-01: Systemic imaging fails to detect metastasis in early stage breast cancer

Background: Current NCCN guidelines for early stage breast cancer (Stage I and II) do not recommend routine systemic imaging in the absence of symptoms or abnormal labs suggestive of distant metastasis. This study aims to determine the frequency and appropriateness of these imaging studies performed, its impact on staging and the factors that influence physicians in ordering these imaging studies.

Methods: Patients with stage I and II breast cancer at initial presentation were retrospectively identified between years 2011-2015 from the tumor registry. Charts were reviewed to determine patients who got systemic imaging (CT scan, non-breast MRI, bone scan or PET scan) within 6 months of diagnosis. Provider notes and laboratory data were analyzed to establish the appropriateness of ordered imaging studies and if the imaging altered the stage. For each patient in the study, age at diagnosis, the grade of the breast tumor, hormonal receptor status and HER-2 status was documented. Statistical analysis was done using appropriate tests.

Results: A total of 1067 patient charts were screened, of which 882 were identified for inclusion in the study (544 stage I, 338 stage II). Amongst the cohort, 18.57% (101) of patients with stage I and 50.89% (172) of patients with stage II cancer received imaging studies within the first 6 months of diagnosis. Only 12.68% (69) of stage I patients and 18.24% (62) of stage II patients were judged appropriate for imaging based on symptoms and lab results suggesting metastasis. In the imaged cohort of Stage I patients, only 4.35% (3) of the appropriately imaged group and 13.33% (4) of the inappropriately imaged group had a change in stage. Similarly, in the Stage II cohort, only 4.84% (3) of the appropriately imaged group and 8.18% (9) of the inappropriately imaged group saw a change in state. The difference in stage change in the appropriately and inappropriately imaged groups was not statistically significant. (p = 0.11 for Stage I, p=0.41 for Stage II). Only 5.9% of Stage I and 2.9% of Stage II imaged patients changed to stage IV. Grade 1 patients were less likely to receive systemic imaging than grade 2 and 3 patients ((p &lt;0.001). Similarly, the difference in imaging rates ordered in patients with ER and/or PR negative status versus ER and PR positive status was significant (p=0.0004). Triple negative (p &lt;0.001) status and age≤ 50 years were statistically significant predictors of patients receiving imaging (p = 0.014). HER-2 status alone was not a significant predictor of getting imaged (p= 0.527).

Conclusions: We performed the first ever study to investigate a correlation between the appropriateness of ordered imaging studies in early stage breast cancer and its ability to detect a change in stage. Distant metastasis identification among stage I & II patients was extremely rare among both appropriately and inappropriately imaged groups. Our findings suggest a wide prevalence of inappropriately ordered imaging studies in Stage I and II breast cancer as well as limited utility for even appropriately ordered ones. Further, other factors such as grade of the tumor, ER/PR/HER2 status and age were found to be statistically significant predictors of whether patients received imaging studies.

Citation Format: Gaba AG, Kraft R, Stjern BK, Monu M, Gunderson MA, Hanish C, Samreen A, Paladugu G. Systemic imaging fails to detect metastasis in early stage breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-01-01.

Risk Factors for Concomitant Collateral Ligament Injuries in Children and Adolescents With Anterior Cruciate Ligament Tears

Background:

Risk factors for concomitant ligament injuries (CLIs) of the lateral collateral ligament (LCL) and medial collateral ligament (MCL) in children and adolescents with anterior cruciate ligament (ACL) tears are unknown.

Purpose:

To determine whether body mass index (BMI), sex, age, and injury mechanism are associated with CLIs in children and adolescents with ACL tears and whether CLIs are associated with meniscal and chondral injuries and a delay to surgery.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We reviewed the records of patients aged ≤18 years with ACL tears from 2009 through 2013 for sex, age, height, weight, CLI, injury mechanism, intra-articular injury, and time to surgery. Patients were assigned to groups according to the presence of a CLI (CLI group) compared with the presence of an isolated ACL tear (ACL group). BMI was categorized as underweight, normal weight, or overweight/obese. The older group was defined as age ≥14 years for girls and ≥16 years for boys. Logistic regression, Mann-Whitney U tests, and chi-square tests were performed (alpha = 0.05).

Results:

We included 509 patients (267 girls) with a mean age of 15 years (range, 6-18 years) at the time of injury. There were 396 patients (78%) in the ACL group and 113 patients (22%) in the CLI group (90 with MCL, 11 with LCL, and 12 with both MCL and LCL injuries). Groups had similar proportions of overweight/obese patients (P = .619) and girls (P = .104). Older age (odds ratio [OR], 2.0 [95% CI, 1.3-3.3]) and contact injuries (OR, 2.2 [95% CI, 1.4-3.4]) were associated with CLIs. The CLI group had a higher proportion of chondral injuries (P = .001) but not meniscal injuries (P = .295) and presented to surgery earlier than the ACL group (P = .002).

Conclusion:

Older age and contact injuries were associated with CLIs in children and adolescents with ACL tears, whereas BMI category and sex were not. CLIs were associated with a higher proportion of chondral injuries but not meniscal injuries and were not associated with a delay to surgery.

Referral Patterns of Emergent Pediatric Hand Injury Transfers to a Tertiary Care Center

Several studies have identified the inappropriate use of emergent interfacility transfer as an opportunity to improve health care use. The authors sought to identify common characteristics among children who were transferred from a community hospital to a pediatric tertiary care center for definitive treatment of hand/wrist injuries. All patients undergoing emergent transfer to a pediatric Level I trauma center and academic tertiary referral center for evaluation and management of injuries to the hand/wrist during the 2-year study period were retrospectively identified. Demographic and transfer data were abstracted from the medical record. Referring hospitals were subcategorized by the presence or absence of hand surgical emergency department coverage and the capability to admit/operate on children. Overall, 169 patients were identified who transferred to the authors' institution for hand injuries. There were no differences in the day or time of transfer. Of those transferred, 59 (35%) were admitted for definitive care, of whom 51 (86%) required a surgical intervention within 24 hours. Of the remaining 110 (65%) patients discharged from the emergency department, 27 (25%) underwent elective surgical intervention within 2 weeks. There were a greater number of transfers from institutions without the ability to admit children, regardless of hand surgical emergency department coverage status. Understanding pediatric referral patterns may improve use of emergency department facilities because most patients who were transferred were discharged the same day. Educational outreach and improved interfacility communication may result in enhanced resource use for evaluation and management of pediatric hand injuries.

Potential paths to pedagogical excellence: early stage career support

Faculty who desire to improve student learning through improved teaching have a variety of opportunities to address change. University educators have as a goal to improve the competence of graduates through improved teaching and learning in their institutions. This article draws upon the scholarship of obtaining feedback on teaching performance from a variety of sources and describes opportunities for young faculty to develop and enhance their skills in order to improve student learning. The experiences described can also serve as guidance for other faculty in their role as faculty mentors and for administrators in their role of supporting and encouraging improvements in the teaching/learning processes in their colleges and universities.

Full coulomb calculation of stark broadened spectra from multielectron ions: A focus on the dense plasma line shift

Recently, there has been growing experimental evidence for redshifts in line spectra from highly ionized, high-Z radiators immersed in hot, dense plasmas [O. Renner et al., J. Quant. Spectrosc. Radiat. Transf. 58, 851 (1997); C. F. Hooper et al., in Strongly Coupled Coulomb Systems (Plenum, New York, 1998); N. C. Woolsey et al., J. Quant. Spectrosc. Radiat. Transf. 65, 573 (2000); A. Saemann et al., Phys. Rev. Lett. 82, 4843 (1999)]. A full Coulomb, multielectron formalism of line broadening due to perturbation by plasma electrons will be presented. A red line shift and asymmetries arise naturally from employing a full Coulomb expression for the perturber-radiator interaction, rather than applying the dipole approximation. This formalism can now be applied to arbitrary multielectron radiating ions.